INTRODUCTION:
In Colombia, there are no specific studies on the prevalence of heroin use.
This paper reviews the patterns of substance use in a consumer group in the
city of Medellín and its metropolitan area, showing that consumption
is becoming a threat to public health due to the particular forms of consumption,
among which risk practices are included.OBJECTIVE: To evaluate the use of heroin in the city of Medellín
and its metropolitan area.METHODS: The study took a mixed approach using multiple-case study to
cover each of the variables and categories proposed; 42 heroin users of treatment
centers in the city of Medellín and its metropolitan area were accessed
between July and September 2008, using the "snowball", technique. Information
was collected by a structured, face to face interview, asking about the type
of heroin consumed, routes of administration, frequency of consumption, equipment
used, consumption practices and rituals that accompany these practices. Quantitative
data were analyzed using the EPI-Info statistical package 2,000 and Atlas ti
qualitative, version 5.5, for Windows.RESULTS: Consumers were predominantly male, single, aged between 18 and
23 years, childless and many had not completed college. Most respondents were
in the middle socioeconomic stratum, had a family history of psychoactive substance
use and had started heroin use between 15 and 17 years. There are special forms
to name heroine, consumers, and rituals to consume the substance. The article
gives details of the heroin consumed, the paraphernalia and associated practices.CONCLUSIONS: The use of heroin is an emerging reality in Colombia. Qualitative-quantitative
studies are necessary to allow us to acknowledge and understand more about this
phenomenon in order to decrease the impact on public health

Keywords:
Heroin. Medellín. Colombia. Consumption patterns.

Introduction

The UNODC estimates
that in 2009 between 12 and 21 million people around the world have consumed
opioids, and three quarts of them have done heroine, that is, about 375 tons
of this substance. Europe and Asia are still considered the main consumption
markets, the first with three million consumers and the latter with a little
over six million (1) (UNODC, 2011).

The UNODC calculations
in the World Drug Report 2012 on opioids consumption, especially prescribed
ones in America is: 1.290.000 consumers in North America, 100.000 in Central
America, 60.000 in the Caribbean, and 840.000 in South America(1).
In USA and the northern Mexican frontier there was data on the heroin consumption,however,
it was unknown in the rest of the continent. Half way through the decade2000,
there are cases in treatment centers in the main cities of Colombia and recently
the Inter-American Drug Abuse Control Commission /OAS reported cases in the
Dominican Republic, Honduras and Chile. (2)

In Colombia, there
are no specific studies on the prevalence of heroin consumption. There have
been some reports regarding such consumption, without specific information on
method of administration; they show an increase of the prevalence, though,a
comparison cannot be established due to the different samples and methodologies
used. The first consumption report on this drug in the country dates back to
1992 in the First National Study on Mental Health and Psychoactive Substance
Consumption(3),showing life and annual prevalence that did not reach
one out of one thousand in the general population. The same study carried out
in 1997 reports a 12 out one thousand in the annual prevalence (4).
A research project carried out with young people between 10 and 24 in 2002 showed
a life prevalence of 11 out one thousand (5). Finally, a recent study
carried out in 2008 shows statistics that display a life prevalence of 19 out
of one thousand and annual and monthly prevalence of two out of one thousand
(6). Table 1.

The consumption
patterns of this substance are associated to the dependence degree and the biopsychosocial
risks that can affect the individual and have important consequences on public
health. The problems caused are related to the method of administration are:
hepatitis, abscesses and infections, cellulitis and HIV/AIDS through infected
needles as well as related to the attitudes and behaviors: criminal behavior,
accidents, family issues, educational dropout and unemployment (7),(8)

There are many
evidences of morbidity caused by this substance. Giner et al.(9)
summarize the effects produced on the body by heroin consumption in the following
table.

The opioids forms
of abuse and dependence are as varied as the cultural means and ends of the
consumption.As well as, the beliefs and customs of the people that consume these
substances for example a business man in Southeast Asia usually inhales an opioid
pipe before going to bed, some Chinese usually drink an opioid brew in water
and a young person who consumes heroin in Great Britain frequently prefers to
smoke it in order to avoid the medical risks of injections and the legal aspects
implied by holding a hypodermic needle with traces of opioids. (10)

The consumption
prevalence is usually in males and this is probably due to the fact that men
prefer higher risk consumption then women. (11), (12), (13).

The purpose of
the study is to describe and analyze the heroin consumption patterns in a sample
of consumers in Medellin and its Metropolitan Area, in order to show the risk
of consumption practices, propose prevention alternatives and motivate other
researchers to carry on with studies and contribute to the knowledge of this
issue in Latin America; for heroin is being produced and consumed in Colombia
and there is a high risk that it will extend to other countries of the region.

Materials and
Method

This research project
has a qualitative-quantitative design, through a multiple case study. The recruitment
of participants for the study was done through drug consumption treatment centers
in the city of Medellin and its Metropolitan area through a "snow ball" technique.
The number of participants was closed once the categories were filled, the sample
was therefore intended and it finally came to be of 42 heroin regular consumers.
Reaching this number was quite hard, due to the access difficulties to consumer
population in general and especially to heroin consumers because it is still
a minority, merely emerging group in Colombia.

A structured interview
was used as a qualitative technique to gather information because it is considered
the most appropriate way to reach the objectives of this study since it is a
way to collect descriptive data based on experiences and the word of person
directly involved in the practices of heroin consumption. The question guide
was written by the researchers based on the existing literatures reviewed and
validated by three professional experts in the field of drug-dependency and
who have had contact with heroin consumers. Besides, a pilot was carried out
with three heroin consumers in order to validate and to tune up the instrument.
The interview was carried out face to face and for about 40 minutes. The questionnaire
gathered the needed information on the characteristics of the consumption and
the consumers. There were also some demographic data as information regarding
age at which consumption began, patterns and heroin consumption frequency at
the time of the interview were required; this information became the quantitative
component of our research project.

The hypothesis
to be tested was the similarity of the consumption and consumer characteristic
to those of heroin users in other countries.

The interviews
were done by four professionals: a specialist in pharmaco-dependency and three
psychologists undergoing the process of specialization in the same field, they
all have deep knowledge on the topic and study context of the city of Medellin
and its Metropolitan Area. The interviews were agreed on through the treatment
center directors and the consumers that were institutionalized in them. For
the contacts gotten from the "snow ball" technique a place for the interview
was scheduled. No economical retribution was paid for this participation.

The quantitative
data were analyzed using EPI-Info 2.000 and the qualitative data with Atlas
ti, version 5,5 for Windows. The analyzed categories were: characteristics of
the substance, consumption and consumers. The data processing included a phase
of codification. First, the contents of the interviews were described per question
based on the transcriptions then the information was grouped into paragraphs
depending on the emerging categories and making "hermeneutical" units. Then,
came the inferential and tendency analysis, focusing on similarities and differences,
it was contrasted with information from secondary sources, afterwards, the findings
were written and supported through arguments and paralleled with the interpretation
of the research group.

The ethics code
that this type of research requires was strictly followed in aspects related
to: permissions to record the interview, anonymity and confidentiality was guaranteed.
All the interviewees signed an informed consent in which they stated that they
voluntarily participated in the study and they were entitled to withdraw from
it at any moment and authorized using the data for academic purposes. The study
underwent the evaluation of the Research Ethics Committee at Fundación
Universitaria Luis Amigó, it was approved and overviewed by this committee.

Results

Sociodemographic
characteristics

The heroin consumers
in this study are mainly male 80,9% (34) and the participant females were 19.1%(8).
the age of the consumers who were interviewed is between 18 and 23 years, 59,5%
(25), 26,1% (11), were at the moment of this study between 24 and 30 years old
and the other14,2% (6) were older than 31.

Most of them (37)
87%are single, 04 (11%) weremarried and one was a widower (2%). Regarding their
schooling level the information was: 38% (11) of them did not graduate high
school, 45% (19)are going to college; (4), 9.5%, hold technical degreesand only
one (2%)had no schooling.

The sample included
all socio economical strata, with a higher presence of middle and low middle
classes, the first with 40% (17) and the latter with 42% (18). The other ones
had 06 consumers from low class (15%) andone consumer from high class with (3%).

Age heroin consumption
began

It is interesting
to observe that the initial consumption of heroin begins at older ages than
other drugs. Among all the people that were surveyed 71% of the heroin consumers
were between 15 and 20 years old for their first heroin experience. However,
the percentage (18%) of them who tried it for the first time when they were
adults stands out. Table 2.

All the heroin
consumers began with marihuana between the age of 8 and 12. None of the consumers
began directly with this opioid. When they came to this substance they were
all poly consumers.

All the participants
informed that they were poly consumers, the consumption of alcohol stands out,
as well as marihuana, cocaine, recreational and non-prescribed medicine as the
most frequently used. Almost all of the participants (95%) used marihuana, their
starting drug more than three times a day.

For all of the
participants heroin is the drug with the highest impact. Most of the consumers
(95%) used it more than three times a day.

All of the people
that were interviewed consumed heroin, but not all of them became immediately
addicted. 90% of them experimented with it and stopped using it for a period
of 03 or 04 months and then used it again, this time they became addicted.

Names for heroin

The most frequent
name heroin consumers in Medellin use for the substance are "H" (43 people),
similar to this name others call it: "hachechina". Other names related
to the color of the substance are: "La mona", "el quipito" (due
to the brownish milk color), "chocofan" the name that some of the people
that were interviewed gave to the Californian modality that is similar to dough
in water and lemon. Other words used by the consumers were: "merca",
"caballo", "guajiro", "guache", "lonchugas", "chanchenco",
and speed-ball when mixed with cocaine.

Names for each
type of consumption and for the consumers

There are different
names that heroin consumers use for each consumption, these are highly related
to the method used to introduce the substance in the body. They generally refer
to the consumption as: flight, trip, "let´s go to sleep", many of these
names are related to the downers and hallucinogenic effects of heroin and "the
cure", "the medicine" when they need relief from not consuming and the beginning
of withdrawal symptoms.

When the consumption
is carried out through the nasal way-inhaled- consumers name it as "pass" or
"lance", the same names are used for cocaine taken this way; "esquirlazo"
if both nostrils are used and "limp" if only one nostril is used. If
it is smoked, they use the name: "shot", "chasing the dragon".
The latter name catches one´s attention since they refer to a technique
used in Asian countries.

When the administration
method is intravenous, consumers name it: "shoot", "prick", "pinched"
all these names are related to the act of introducing a needle in a vein.

On the topic of
how drug consumers name heroin users, the people that were interviewed use a
lot of different names, some very general ones and some related to the administration
method. Regarding the general names some are: "heroin maniacs", "haches",
"hacherolos", "hachinos", "hachesinos", "hachenáutas",
"hachechinos" all these names are based on the way the substance is named
"H" (-hache- in Spanish) and "zombies" because of the way a heroin user
looks when under heroin effects.

The consumers that
inject themselves are called: "yankees", "junkies", "pinchetos", "chutaos".
If the method of consumption is inhaling then they are known as: "güelengues",
and if it is smoked they are known as "gunman" because they "shoot"
themselves.

Morphological
characteristics and presentation of the heroin available in Medellin

Overall everyone
agrees that its color is brownish with some variation towards"creamy" beige
or yellow; few speak of the white heroin. Another characteristic is that it
is a powder with sand like feel, the smells like a "drug store", "sweet butter",
"glue" and "ether" and it has a "sour" taste. The most common presentation in
the market is in small plastic zip lockbags as well as in folded paper like
a firecracker.

The consumers identify
the quality of the substance through its cost, color (tone), texture (tactile
sensation); the taste (the aftertaste it leaves behind on the throat when it
is smoked or inhaled), solubility (in cases of injectable consumption) and finally
because of the psychodysleptics effects produced by the substance. The degree
of refinement the consumers have regarding the purity of the substance without
sophisticated lab tests definitely stands out.

All of the consumers
that were interviewed express that the more expensive the heroin,the better
it is. Many of them state having consumed cheap, low quality heroin, due to
lack of money and the urgency to consume the substance because of the terrible
sensations when they do not consume. They acknowledge that consuming low quality
heroin creates an anxiety to consume quicker, to feel less the effects and therefore
increase the levels of consumption.

Regarding the color
they say that in Medellin and Valle del Aburrá, they can get brown, black
and white heroin. The latter according to most of them (38 people) is of the
highest quality. According to them, the one they most frequently find in Medellin
and Valle de Aburra is "light brown", they say that the lighter the better.
However, few of them (04 people) consider that the darker it is, the higher
the quality. Some testimonies regarding this issue:

"Yeah, the lighter,
the better.....the very light yellow....it is the best quality." (Interview
#8)

"I would tell it
apart by texture and color, if the color was sort of opaque, very brown and
very dark, it was of a lower quality, the less pure it was. The white one is
the best....." (Interview #16)

"....the quality
depends on the color, if it is very brown, it is pure, and if it is like brownish
with white, it´s bad, it´s sour" (Interview #23)

Texture and solubility
are other characteristics that heroin consumers consider have to do with the
purity and clarity. The one that is soft to the touch, not greasy, not lumpy
and that spreads easily over a surface and crushes is considered to be the best.

".....I know it
is good when I crush it. If I crush it and comes out in tiny pieces,...it´s
good..., if there are lumps or bigger pieces, the quality is poor....." (Interview
#49)

"...the purest
heroin is not raspy, the bad heroin, when you are chopping it on paper, it feels
like sand, like it "screeches" the paper, the pure heroin is whiter and when
you chop it on paper, it doesn´t "screech" (it makes no sound whatsoever)"
(Interview #39)

Regarding the taste,
they established that the sour taste on the throat when they smell or inhale
the substance speaks of its quality.

"Because of the
taste, when you inhale it, it goes down the throat like a sour substance and
if it is sour, the heroin is very good. If you do not feel that, it´s
because it´s not good" (Interview #40)

The users that
take it intravenously to talk of its quality refer to the solubility and relate
it to the cuts the "dealers" (people who sell small quantities) make to make
the substance last more, these testimonies illustrate these aspects and their
correlation:

"....there was
a time, that... they were mixing heroin with "chocolisto" (chocolate
powder drink), when you tasted it you could sense the sourness but at the same
time...also feel....the taste of chocolate, and you mixed it and it was bubbly,
and the needle would get clogged and that meant the heroin was bad. I remember
once I bought heroin, I tasted it and it was like powder milk.... " (Interview
#12)

"...you dissolve
it, if it dissolves without heat it´s pure heroin, that´s how you
know. The bad one doesn´t dissolve easily...." (Interview #2)

Finally, regarding
the quality and the substance effect, the interviewed consumers acknowledge
that the high quality heroin has more intense effects that last longer.

"The good one,
I would inject myself and I immediately felt how it laid a hold of me and drug
me, but the bad heroin... I would start itching all over, feeling bad; it basically
was like nothing happened. " (Interview #41)

"The bad heroin,
basically does nothing to you, it sort of calms you down, and the pure heroin
is....total calmness and very pleasurable". (Interview # 23)

"....a good one
can go for about eight or nine hours, and you do not feel as anxious to consume
immediately. The one that´s bad, you immediately feel the need to "junkie
up" again; the effect does not last very long" (Interview #22)

Methods of administration
and reasons for preferences

Out of the 42 consumers
that were interviewed 57% (24) inhale it, 24% (10) consume it intravenously
and 19% (9), alternate between smoking it and inhaling it.

Regarding those
that inject themselves (10), the people that were interviewed say that the most
common places for the shots were: arms, wrists and the back part of the foot.
The reasons to prefer these places were: "easy access to the veins", "you can
feel them and see them" and the foot "to avoid being given away by the marks"

Also, along the
preference for intravenous administration, the informers expressed that as time
went on, consuming any other way did not produce the same pleasure,since their
bodies had developed tolerance to the effects of the heroin and this brought
them to look for other means of administration in order to feel the sensations
the drug gave them in the beginning. Also, others say that they changed to the
intravenous way because when they consumed it this way, they needed a lower
dose; they saved money, because they needed less heroin and also because the
effects were faster and lasted longer.

On the other hand,
the ones that prefer not to inject themselves (32), 09 preferred not to do so
because they were afraid of needles, 08 stated that intravenous administration
is more dangerous than the others, 04 considered that injecting made them more
addicted, 04 expressed that this type of consumption had a higher risk of overdosing
or dying in their sleep and 02 thought that the withdrawal symptoms were higher.
Finally, 05 of the interviewed people openly expressed that they did not inject
themselves because it left marks all over their bodies and they knew other consumers
that did it and had "degrading" marks; that kept them away from this type of
administration.

Finally, the ones
that prefer inhaling defend it saying it is simpler, faster, less flashy (more
discreet) and that doing it in this way they do not lose control that much.

Quantities and
costs of the consumed heroin

Regarding the consumed
doses, the tendencies in the analysis of the data provided by the 42 users that
were interviewed showed that 21% (9) consume about 0,25 g/per day; 25 % (11)between
0,5 y 0,75 g/per day; 34 % (14) 1 g/per day; 8 % (3) 2 g/per day; and 12 % (5)
consumed more than 2 g/per day. The inhaling administration methodreports the
highest consumption frequencyan average of every 2-3 hours;while intravenous
consumption spreads out the most, an average of about 6-8 hours. They all acknowledge
that as consumption increases, so does the quantity of heroin, thus denoting
the development of tolerance in consumers. Figure 1.

Regarding the cost
of the heroin, we observed how one of the participants stated that he spent
under $10.000 Colombian pesos (US 4,50 dollars) to buy heroin, a high percentage
of the people in the sample which included 37 people expressed that they spent
between $10.000 to $40.000 Colombian pesos (US 5 to 21 dollars) on a daily basis.
Only 04 of them stated that they invested more than $40.000 Colombian pesos
(more than US $21 dollars) on a daily basis to consume the substance.

Referring to the
question who do you buy the heroin from? We observed a continuous worry of the
consumer regarding the quality of the product, therefore, most of them emphasized
on the importance of creating groups or networks that can establish a trust
bond between consumers and "dealers". This way, they can counterattack the risks
of "low quality", "mixtures" and "cuts" that can go anywhere from poisoning
to reducing effects, possibly even death.

Even though some
of the people that were interviewed acknowledged that heroin is a restricted
substance, on the issue of how easy it is to get it, they stated that they are
in the world of consumption and it is easy to get. In 28 of the cases, the interviewees
buy heroin from close people: friends or trusted people. This closeness gives
them the security of the quality, availability, frequency and even credit margin.

On the other hand,
14 of the consumers buy from "dealers" who are available 24 hours and that guarantees
the availability of the drug. There are two types of circumstances, on one side,
there is the consumer that knows the place where the drug is sold and goes over
there to buy it; on the other side, there is the "dealer" that can be contacted
through a mobile phone and this person moves around the city for security reason
and when called informs the whereabouts of their current location or delivers
the drug. Table 3.

Elements used
in the administration of heroin.

In heroin consumption
practices elements are used depending on the method of administration. To inhale
there is a straw or a pocket knife or an id card, to extract the substance from
the little bag and introduce it in the nose.

When injected they
use an aluminum tray or spoon or even the backside of a can or a soda bottle
cap that hold some liquid, a lighter to warm up the heroin, insulin needles,
distilled water, tap water, alcohol or any type of liquor to dissolve the drug,
a tourniquet (a belt, shoe laces or by pressuring with the legs) and sometimes
cotton or a cigarette filter.

The smoking method
requires aluminum foil, a straw or a rolled up piece of paper or carton and
a lighter. Table 4.

Consumption
ritual

Getting to know
the rituals associated to drug consumption brings important elements to prevent
morbidity related to the administration methods and the use of inappropriate
consumption techniques.

The first step
for heroin consumption that all the consumers follow is to get all the necessary
elements depending on the method of consumption. The details of consumption
rituals are described in table 5.

Places of consumption

There aremany places
used for heroin consumption, both public and private. The bathrooms, their houses,
friend´s houses, city parks, university green zones, discos and bars,
cars, parties and country homes.

With whom do
you consume heroin?

Twenty seven of
the interviewed patients consume with friends and develop group practices around
heroin. Most of the consumers attribute this preference to the fact that the
group can share the expenses to buy the doses and maintain common rituals; also
they can get back up in case of an overdose risk. Some testimonies show this:

"It was always
good to consume it with someone else because you know that it is a very dangerous
drug, and all of a sudden, if you do not know how to consume it, you can, at
once, cause an overdose and being with another person gives you a sense of security
and if something happens your partner can help you" (interview #4)

"There are some
symptoms that we pay attention to: we look at lips, if they turn blue, you touch
the heart, but main thing were the lips, if they were purple it´s because
the person had a cardiorespiratory arrest, immediately to the hospital, that
is what we did, take care of each other." (interview # 32)

On the other hand,
sixteen of the interviewed consumers agreed that they prefer solitary consumption;
they claimed that this decision is based on maintaining anonymity and addiction
a very intimate world, and they can do it without being observed or judged by
others.

Nine of the consumers
consumed heroin with their couples in order to establish a love tie, take care
of each other and experiment pleasurable sexual intercourse.

"I had a girlfriend
who used to consume with me. The ritual with her was basically the same one
I did when Iwas alone, but with her we were naked and we played some music and
played movies...I would inject her and she would do me and we would go to bed
to wait for the trip to pass, we slept naked, in the beginning we would have
sex quite often, but with time you lose interest."(interview # 8)

Two of the consumers
did it with family members (uncles, cousins) and two consumed in public places
with unknown people.

Out of the 42 people
that were interviewed, ten (23.8%) have used intravenously and six of them (14%)
have shared needles and paraphernalia (water, soda caps or spoons to dissolve
the heroine, cotton to filter the substance, etc.)

Heroin consumers'
drug mixing

Different epidemiological
and quantitative studies on the characteristics of heroin consumers have shown
that they usually are poly consumers (12). In this paper one can evidence a
high tendency among the interviewed heroin users to mix drugs looking for different
effects. In some cases,consumption was done simultaneously and in other cases
it was done between heroin consumptions. Many of the cases of intoxication and
overdose symptoms referred by the consumers were caused by substance mixing.
The drugs the consumers usually mix are:

- Out of the 42
heroin consumers 16 of them mixed it with marihuana (so called "cagaito",
"dulcecito", "cooper", "merco" or "nevado").

- Fourteen of them
mixed it with cocaine (so called "speed ball", they pronounce it: "spilwold",
"espir", "spirpool", spik" or also called "coffee with cream"—characteristic
color of this mixture--.

- Eight of them
claimed to have mixed heroin with pill like benzodiazepine.

- Five consumers
mixed heroin with cigarettes, however, this research project did not establish
whether it is used under the technique known as: shooting an antiaircraft gun
<<ackack>> (in this technique heroin powder is pushed into one extreme
of the cigarette, the person has to smoke the cigarette upwards so the powder
doesn't fall out, this position is similar to an antiaircraft gun). A variation
of this technique is smoking cigarettes that have heroin in them.

- Four of them
mixed heroin and alcohol (liquor). Heroin and crack, heroin and methadone and
heroin and acids (LSD): each one with one reference.

When you do
not get heroin, what substance do you use to replace it?

The dependence
produced by heroin and the consequent withdrawal syndrome when it is not taken
brings consumers to use other type of substance to feel better. In the substances
that are consumed by the 42 people that participated in this study we found
these mixtures: Rivotril (benzodiazepine) and marihuana; Rivotril, cocaine and
alcohol; tramadol, codeine, methadone and morphine (opiate derivate) and Rivotril,
carbamazepine, akineton and hydroxyzine. It is important to notice that none
of these medicines were formulated by a doctor, they were self-prescribed and
many of them bought in the black market.

Parallel activities
to heroin consumption

In the interview
analysis a great number of activities that the consumers do during their consumption
practices came up: most of them listen to music (their favorite genres are:
rock, reggaeton (urban music), electronic music, punk, salsa, reggae and hip-hop);
watch TV (some of them without volume); have sexual intercourse, exercise (walk,
skate, soccer), sleep (because the drug for most of them makes them sleepy or
totally relaxed); watch videos or movies, paint (one of the patients for example,
says that he tried to take advantage of the hallucinations to draw the abstract
scenery that played in his mind), drive (some of them expressed that they liked
driving a motorcycle or a car because the speed was magnified), talk to their
consumption groups, surf the web, listen to the radio, write, read, play music
instruments, play video games or cards.

Discussion

In Colombia, there
is only one previous research project on characteristics of heroin consumers
and consumption, it is the one done by Pérez Gómez (14).
This qualitative research was carried out through interviews to 96 drug consumers
who were part of treatment centers in 07 cities of Colombia. From the 96 people
that participated in the study, 21 were heroin consumers. The research, though
focused on the transitions of drug consumption in the country, openly asked
about the characteristics of heroin consumers and the results were: most of
the people that participated "do not know" the characteristics of heroin consumers.
The rest of the people based their opinions basically on the consequences that
heroin produces in the physical appearance and the symptoms of the withdrawal
syndrome.

The same author,regarding
the method of administration, says that smoked heroin consumption is more common
than the intravenous one, but those who smoke it have a tendency to do it in
an irregular fashion and not very frequently, while those who inject it tend
to do it on a daily basis (15). In the initial stages, smoked heroin
consumption is done in groups and they all pay for it, but later becomes an
individual activity (to avoid sharing). In our study the most frequent method
of administration is inhaled.

The same study
explained the transition in drug consumption all the way to heroin, showing
a tendency to go from benzodiazepine to heroin. The proportions of consumers
between the different social classes reported users from middle class with a
rate of 1:3, while low class is 1:8 (14). In our study, middle class
showed the highest level of consumption.

The age at which
consumption begins in the Pérez Gómez study (14) is
16 for females and 21 for males; the rate regarding gender is 1:10 in females
and 1:3.5 in males. In our study, the age at which consumption began was higher
64% used heroin for the first time after 18 years old, but about a third 36%
(16) did it in adolescent years (between 15 and 17). The proportion
of women in our research is much higher 08 women out of 42 participants, this
might be due to the fact that the snowball technique was used and consumers
refer to their own couples, the ones that begin consuming due to their pressure
(15).

The twenty one
heroin consumers in this study had a long previous history of consuming other
drugs, just like in ours. Heroin, for all of them, became the substitute for
all other substances. We also came across this finding. The reasons that they
expressed for not injecting themselves are of all sorts, but the ones that stand
out have to deal with creating a greater dependence, a higher risk of death,
health issues and fear of needles; in our study likewise.

On the issue of
socio-demographic profiling of heroin consumers in our country there is no data.
The only information is the one presented in this study which matches the studies
carried out by Sánchez y Borjano(12) who in Spain found that
heroin addicts were mainly single, childless males, about 26 years old. Whereas
in our research they were younger (18 to 23 years old) and with a higher level
of education 88,3% had received high school and college education, in Spain,
however, most of them had not finished elementary school, this information was
confirmed by the authors who also report major prevalence in people with low
academic education (16), (12), (17).Regarding marital status similar
data was found in studies carried by Amodia et al, (18); Marina (19);
CerveraValderrama, et al., (20); San Narciso, Carreño, et
al., (21).

Regarding the consumers
gender Gutiérrez, Sáiz, García, Fernández, González,
Fernández y Bobes(22) found in their study that heroin consumers
were mainly males between 25 and 29 years old, the rate between sexes was 85%
male and 15% female; quite similar to our situation (19%) and what most other
authors present as well (18), (23), (19), (24), (20), (25), (21).

Heroin consumption
in females, though prevalence is low, deserves to be mentioned because of the
psychosocial and socio-cultural implications that differentiate them. Orte(26)
affirms that one of the reasons that there are less female consumers might be
that males are more prone to dangerous or risky drugs, while women show a higher
consumption of legal medicines. The beginning of female consumption is also
different. In an ethnographic study by Meneses (13) some differences
were pointed out: previous consumption of other drugs (tobacco is the most common
in all of them, followed by alcohol) for them heroin is the first illegal drug
they try (males have previously consumed other drugs); they are familiar with
the substance and the environment, that is, they have observed others in their
environment (this period is longer in women than in men). The more common methods
of administration in women are inhaled or smoked, they are usually started on
this substance by another person (possible a couple, friends or family members).They
finance their consumption with activities that are not considered highly criminal
and they usually do not have a hard time getting the heroin, for many of them
do it through prostitution.

According to genre
the consequences of being a heroin-maniac are not the same for men than for
women, the social stigma is greater on women, especially for their role as mothers
and wives. Due to their condition, the consequences are more problematic due
to maternity hood (delegating their responsibilities to others makes it very
hard to get their children back, also they have to face the children´s
possible reproaches for their absence), in a new relationship (it might be difficult
for a man to accept their past of heroin consumption because of the possibility
of having AIDS), the work market (due to lack of professional education, aspiration,
past and stigmatization) and health deterioration usually by genital morbidity
like STD, amenorrhea, unwanted pregnancies and abortions (13).

Regarding age of
starting the consumption, it is important to point out that in our study 36%
of the consumers began before the age of 18 which has direct implications in
public health due to the possibility of developing a greater dependence and
therefore a greater bio-psychosocial deterioration and a greater risk of transition
towards intravenouseven with the risks associated to bad practices and getting
HIV/Aids, hepatitis B and C. Most of the consumers of our study began consumption
after the age of 18 and this data matches that of the De la Fuente De Hoz, et
al (17) study.

On the other side
and regarding the way consumers name heroin and the nicknames they use to name
consumption and consumers, it is important to add that jargon sometimes appears
to be universal. This must be due to the globalization of mass media, especially
internet which allows themeasy access to information, set up groups through
social networks to share their experiences and even provide the substance. Some
consumers of our study name heroin as "caballo" (horse) the name they
use in Spain, like "chute" to refer to inject and "junkie" for
the one that consumes through intravenously (27). The other names
that our research provides are closely related to the appearance of the substance
and the method of administration. Other names for the substance described by
Alvarez andFarre(28) are: "smack" ("pasta"), "H" (the name they use
in Colombia), "skag" ("white powder"), and "junk" ("lenguazo"), "Mexican
black tar" ("goma"), "agua de primavera", "caballo", "Harry", "leónrojo"
or "reina".

Taking into account
heroin characteristics and the aspects described by Stockley(29)
and confirmed by Gómez (30) regarding the color of the substance
and the degree of purity, we can state based on the narrations the consumers
of heroin provided for this research, that consumers in Medellin and its metropolitan
area have access to three types of this drug: brown, white and black heroin;
the most common one is brown one or brown sugar. They are being produced by
Colombian drug traffickers to be sold in illegal international markets but due
to police control, many times it stays in the country and it is therefore sold
in local markets.

The heroin named
number 3 known as Brown sugar seems to be the type that is more common in the
world market. It has originally come from the gold triangle made up of Laos,
North of Thailand and Northeast Burma, its aspect is earthy, lumpy, dirty gray,
brown, terracotta or pale yellow, its texture is similar to building plaster.
The content of heroin is between 25 and 50% and it is generally meant to be
smoked. This type of heroin also produced in Mexico and called Tecata,
has a texture like very dry granulated soil. Its color has different shades
of chocolate and it is commonly sold in the American west coast. (29)

There are also
references to Heroin number 4, also known by the Thai or Chinese name, it is
the most refined and the quantity of heroin is about 90%, before the substance
is manipulated. The color is off white or yellowish and it is fine and spongy.
Its texture is that of powder milk mixed with some sugar and it is destined
to either be smoked or injected intravenously or subcutaneous.(29)

In the information
that was gathered, there is reference to a heroin that Gómez(30)
has denominated "Black Tar", this type of heroin is very common in the American
market, especially in the west coast; its appearance is similar to tar or coal
rocks, a dark brown color, almost black. This heroin comes from Mexico, and
its process is deficient and coarse, it is cut-mixed-with wheat flour powder;
it is sold to be injected, but it is also acquired by some bands that put it
through the refining process again to make it look that the Asian one.

The type of heroine
that is produced and that is available in the market has important implications
regarding the method of administration and its consequent problems. De la Fuente,
Saavedra, Barrio, Royuela, Vicente confirmed this in a study carried out in
Madrid and Sevilla in Spain; it seems that in the first one there is an almost
exclusive circulation of heroin base and therefore it can be smoked, inhaled
or injected and in Barcelona the hydrochloride heroin predominates not meant
for smoking so the way to consume it is through injection.(31)

Taking into account
the methods of administration a paper by Bravo and Colbs revealed that in Spain
most users began using heroin by smoking it in Sevilla(88.9%), Madrid (65.6%)
and inhaled (46.6%) orsmoked (39.7%) in Barcelona. Beginning through injection
was rare (4%). Most of them took less than 6 months between the first use and
weekly using. In Barcelona, when they began using weekly, the sniffing method
had lost its relevance to favor injection and smoking in Madrid (33).
These findings were also similar in our study, except for the step towards frequent
consumption, from the beginning to the weekly consumption was shorter about
04 months; it is an important aspect to consider because it shows that consumers
are arriving to dependence at an earlier age (19). Finally and according
to these authors (17) corroborating previous studies by De la Fuente,
Barrio, Royuela, Bravo, the method of using heroin can change with time and
not always toward injection (considered the most efficient in terms of effect/cost).(33)

Very close to the
method of administration and to the morbidity that this can cause, it is very
important to keep track of injection places; in specialized literature it is
very common to find some of the referred places are arms around elbow folds
or the back of the hands (31). It is the same situation in our environment.
However, some other places referred by our consumers like the back of the feet
to hide the marks left by this practice called our attention.

A lot of the literature
has reviewed the risks of bad practices of injection and the incidence on HIV/AIDS
(34) among heroin consumers. Along with infectious pathology, there are also
hepatitis B and C also one of the most treated issues in this type of users
(35).

Now, eventhough
aids and hepatitis seem to have pushed other infections to a second place, it
is true that drug users have a risk of getting all sorts of infectious pathologies:
cutaneous infections and in soft parts, bone and joint infections, ocular affectation,
intravascular infections—especially
endocarditis--, pulmonary infections including tuberculosis, sexually transmitted
diseases and others less relevant like tetanus, botulism and malaria, all these
infections associated to parenteral drug addiction (36)

Some studies have
also shed light as to the places where users of this drug consume. Knowing them
well is necessary to understand the risks and consequences of practices related
to injection, in aspects dealing with aseptic conditions of the places and the
accessibility to water to dissolve the substance. Consuming in not ideal conditions
can represent abscesses in needle punctures, septicemia, and unnumbered infections.
In Madrid and Barcelona, their favorite places to use heroin were the zones
of drug dealing and mass drug use, followed by the places where they lived and
open spaces (streets, squares, parks, etc.). Whereas in Sevilla they barely
consumed in drug dealing and mass drug use zones, showing preference for accommodations,
open spaces, and other places (17). The latter one seems to be the
tendency of Medellin and its Metropolitan Area consumers, as was gathered in
our research. This aspect led us to question the presence of parents and family
members, do they not know that there is consuming in their own houses?

Related to the
consumption sites, another aspect that has been documented is related to overdoses,
it could have a connection with what has been denominated as behavioral tolerance
which could explain some sudden deaths in heroin users. This tolerance would
present itself before an expected dose of drug but it would not be there for
the same unexpected dose, the environmental condition being whether the quantity
of the drug was expected or not. This would explain the possibility that some
overdoses take place whileadministering the drug in an unusual context, whether
it is location or company (38), (39). Likewise, consuming in public
zones would be more associated to suffering a deadly or not overdose, probably
due to buying in open scenarios where dealers are usually unknown and fluctuating,
being this a risk factor itself (40). Besides, this consumption in
open scenes is more susceptible to becoming object of police raids and the fear
of these police situations makes them consume quicker when they are in public
places and it is more probable that the overdose be attended and not be deadly
(42).

Another relevant
finding is the presence of drug mixture in consumers of this study because of
the risks and consequences that this practice has on individual and group health.
We found that multiple substances are consumed simultaneously, just like other
researchers found. In Madrid De la Fuente et al (17) found frequent
references to the mixture of heroin and cocaine—speed
ball, tobacco, marihuana, alcohol and hypno-sedatives. Heroin users rarely consume
only one substance. The common practice is consuming several drugs whether they
are central nervous system depressants or not. The combined consumption of two
or more depressant substances to sub-lethal doses can enhance its effect and
produce death by overdose; this is the case of the concomitant heroin and alcohol
or benzodiazepine consumption (43), (44), (38). Whereas the concomitant
heroin and alcohol use seems unquestionable as cause of overdose, it is not
so with consuming heroin and benzodiazepinewithoutcontroversial results (38),
(41).

In our work we
found that the interviewees did not know the risk and consequences of such practices,
many of them enhancers tothe depressant effects of heroin (marihuana, benzodiazepine,
alcohol and opiate derivate) that explains the references made by consumer's
regarding their presence in intoxication and overdose signs and symptoms.

Finally and although
we did not come across studies to compare our findings in relation to parallel
activities and consumption, except for the references of accidentsamong consumers
that supposedly drive while under the influence.A fact that was also corroborated
in our study and makes control intervention on behalf of the authorities necessary,
we also consider important to acknowledge other everyday actions that the participants
in this study carry out when under the influence like listen to music, watch
TV, work out, watch videos, draw, paint, talk, surf the web, listen to the radio,
read, write, play musical instrument, play cards which shows a level of "normality"
and "functionality" of these consumers, this aspect might come to be because
of the little time they have been doing heroin, for the cognitive, emotional
and social deterioration the substance brings them to is undeniable.

Limitations
and conclusions

This study represents
a small sample of consumers in Medellin and its Metropolitan Area, it is therefore,
necessary to take bigger samples in order to confirm these results. Data likewise
cannot be extrapolated to other regions of Colombia because consumer and consumption
characteristics tend to differ within the same country, as has been demonstrated
by other research projects (32).

This research has
demonstrated the hypothesis regarding the similarity between both heroin consumers
and consumption in Medellin to those of other counties and puts forward the
importance of knowing consumer patterns, customs, ritual, methods of administration
and consumer characteristics like a valuable element to prevent possible consequences,
reduce impact on public health and be ready for an epidemic that has already
reduced other toxic maniac populations like the Spaniard, where basically all
heroin IV users became infected with HIV and hepatitis (45), (46), (32).